Provider Demographics
NPI:1073716262
Name:RESPIRATORY PHYSICIANS OF SOUTHWEST WASHINGTON
Entity Type:Organization
Organization Name:RESPIRATORY PHYSICIANS OF SOUTHWEST WASHINGTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:WAYLON
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-754-1739
Mailing Address - Street 1:3920 CAPITOL MALL DR SW
Mailing Address - Street 2:STE 304
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-8700
Mailing Address - Country:US
Mailing Address - Phone:360-754-1739
Mailing Address - Fax:360-236-1450
Practice Address - Street 1:3920 CAPITOL MALL DR SW
Practice Address - Street 2:STE 304
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8700
Practice Address - Country:US
Practice Address - Phone:360-754-1739
Practice Address - Fax:360-236-1450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00013879174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1029578Medicaid
WAGAB01394Medicare PIN